Texas Administrative Code
Title 26 - HEALTH AND HUMAN SERVICES
Part 1 - HEALTH AND HUMAN SERVICES COMMISSION
Chapter 351 - CHILDREN WITH SPECIAL HEALTH CARE NEEDS SERVICES PROGRAM
Section 351.16 - Procedures to Address Program Budget Alignment
Universal Citation: 26 TX Admin Code ยง 351.16
Current through Reg. 49, No. 38; September 20, 2024
(a) The department must analyze actuarial cost projections concerning program administrative and client services to estimate the amount of funds needed in the fiscal year by the program to serve program clients and shall monitor such program cost projections and funding analyses at least monthly to determine whether the estimated amount of funds needed by the program will:
(1) exceed the
program's appropriated funds and other available resources for the fiscal year;
or
(2) be less than the program's
appropriated funds and other available resources for the fiscal year.
(b) When the program projects that the estimated amount of funds needed in the fiscal year by the program to serve program clients will exceed the program's appropriated funds and other available resources for the fiscal year, the program shall use the following methodology to reduce or limit the amount of funds to be expended by the program:
(1) give clients and providers who
will be directly affected written notice of any reductions or limitations of
services, coverage, or reimbursements;
(2) take the following actions in the order
listed only until the projected amount of funds to be expended by the program
approximately equals, but does not exceed, the program's appropriated funds and
other available resources:
(A) implement
administrative efficiencies while avoiding changes which may jeopardize the
quality and integrity of the program service delivery;
(B) establish and administer a waiting list
for health care benefits according to the procedures in this section;
(C) at the same time the waiting list is
established, the program shall:
(i) provide
only limited prior authorization for family support services for ongoing
clients, as determined by the medical director or other designated medical
staff, only in order to continue services already being provided at the time
the waiting list is established, when the specific services are required to
prevent out-of-home placement of the client (as documented by the program
regional case management staff or contractors), or when the provision of such
services is cost effective for the program;
(ii) disallow prior authorization (coverage)
of diagnosis and evaluation services for applicants who qualify for up to 60
days of program coverage for diagnosis and evaluation services only and refer
such applicants to case management services; and
(iii) allow limited prior authorization of
diagnosis and evaluation services on a short-term basis only when such
information is needed to assess whether clients on the waiting list have
"urgent need for health care benefits" as described in subsection (e) of this
section and only with prior authorization and approval by the medical director
or other designated medical staff.
(D) place new applicants or re-applicants
with lapsed eligibility who are determined eligible for program health care
benefits (new clients for health care benefits) on the waiting list. These
clients will be ordered on the waiting list according to the date and time the
client is determined eligible for program health care benefits;
(E) reduce or limit reimbursements for
contractual service providers while avoiding changes which may jeopardize the
integrity of the contractor base and thereby decrease client access to
services;
(F) place clients who are
eligible to receive program health care benefits and who currently are not on
the waiting list (ongoing clients for health care benefits) on the waiting
list. These clients will be ordered on the waiting list according to the
original date and time that starts the client's latest uninterrupted sequence
of eligibility for program health care benefits and in the following order of
movement to the waiting list:
(i) ongoing
clients for health care benefits who have one or more sources of substantial
health insurance coverage (such as Medicaid, CHIP, or other private health
insurance similar in scope) in addition to the CSHCN Services Program (not
including those ongoing clients for whom the program pays the insurance
premiums);
(ii) ongoing clients for
health care benefits in the following order by age groups: 21 years of age or
older, 20 years of age, 19 years of age, 18 years of age; and
(iii) all other ongoing clients for health
care benefits who do not have an urgent need for health care
benefits;
(G) employ
additional measures to reduce or limit the amount of funds to be expended by
the program as directed by rule.
(c) If the procedures described in subsection (b)(2)(A) - (G) of this section enable the program to project that the estimated amount of funds to be expended by the program in the fiscal year approximately equals, but does not exceed, the program's appropriated funds and other available resources, the program shall take the following additional steps in order to provide health care benefits to as many clients with urgent need for health care benefits as possible who are currently on the waiting list.
(1) generate cost savings by taking the
following steps in the order listed:
(A) give
clients and providers who will be directly affected written notice of any
reductions or limitations of services, coverage, or reimbursements;
(B) reduce or limit reimbursements for
contractual service providers while avoiding changes which may jeopardize the
integrity of the contractor base and thereby decrease client access to
services; and
(C) employ additional
measures to generate cost savings as directed by rule.
(2) utilize cost savings generated to remove
as many clients with urgent need for health care benefits as possible from the
waiting list and provide health care benefits to those clients. Clients with
urgent need for health care benefits will be removed from the waiting list
according to the original date and time that starts the client's latest
uninterrupted sequence of eligibility for program health care benefits and in
the following group order:
(A) clients who are
less than 21 years old and who have an urgent need for health care benefits as
described in subsection (e) of this section;
(B) clients who are 21 years of age or older
and who have an urgent need for health care benefits as described in subsection
(e) of this section;
(3)
provide health care benefits (which may or may not include coverage of
outstanding bills for health care benefits) for clients with urgent need for
health care benefits who are removed from the waiting list;
(A) as long as program cost savings funds are
available; and
(B) if the
outstanding bills for health care benefits are for dates of service that are
within the time period that program cost savings funds are available and
provided the client was eligible for program health care benefits at the time
of the dates of service;
(4) provide limited health care benefits or
payment of outstanding bills for health care benefits for clients with urgent
need for health care benefits who are on the waiting list and remain on the
waiting list. The program's coverage of such health care benefits may be
limited in scope, amount, and duration and is not intended to be sustained over
time. If limited health care benefits coverage includes coverage of family
support services, the coverage of family support services must be limited
according to the parameters set forth in subsection (b)(2)(C)(i) of this
section. Clients with urgent need for health care benefits who are on the
waiting list will be served in the same order used in paragraph (2) of this
subsection to remove clients with urgent need for health care benefits from the
waiting list. This coverage may be provided to clients with urgent need on the
waiting list prior to or at any point during activities described by paragraphs
(2) - (3) of this subsection only:
(A) when
projected cost savings funds are projected to be insufficient to remove clients
with urgent need for health care benefits (or additional clients with urgent
need for health care benefits) from the waiting list and maintain continuous
program health care benefits coverage for those clients or when projected cost
savings funds may lapse if not expended in this manner;
(B) as long as program cost savings funds are
available; and
(C) if the
outstanding bills for health care benefits are for dates of service that are
within the time period that program cost savings funds are available and
provided the client was eligible for program health care benefits at the time
of the dates of service.
(d) When the program projects that the estimated amount of funds to be expended by the program in the fiscal year is less than the program's appropriated funds and other available resources due to the cost reduction, limitation, or deferral procedures implemented according to subsections (b) or (c) of this section, or the program's receipt of additional funding, or funding analysis resulting in a projected amount of unobligated funds, the program shall increase the amount of funds to be expended by the program.
(1) In an effort to expend
unobligated funds (except for unobligated funds resulting from program actions
taken according to subsection (c) of this section), the program shall utilize
the following steps in the order listed only until the program projects that
the estimated amount of unobligated funds will be expended by the program
during the fiscal year:
(A) take clients off
the waiting list according to the original date and time that starts the
client's latest uninterrupted sequence of eligibility for program health care
benefits and in the following group order:
(i) clients who are less than 21 years old
and who have an urgent need for health care benefits as described in subsection
(e) of this section;
(ii) clients
who are 21 years of age or older and who have an urgent need for health care
benefits as described in subsection (e) of this section;
(iii) all other clients who are less than 21
years old who do not have an urgent need for health care benefits;
and
(iv) all other clients who are
21 years of age or older who do not have an urgent need for health care
benefits;
(B) provide
health care benefits for clients taken off the waiting list as long as program
unobligated funds are available;
(C) provide limited health care benefits for
clients who are on the waiting list and remain on the waiting list, payment of
outstanding bills for health care benefits for clients who are on the waiting
list and remain on the waiting list, or payment of outstanding bills for health
care benefits for clients who have been taken off the waiting list. The
program's coverage of such health care benefits may be limited in scope,
amount, and duration and is not intended to be sustained over time. If limited
health care benefits coverage includes coverage of family support services, the
coverage of family support services must be limited according to the parameters
set forth in subsection (b)(2)(C)(i) of this section. This coverage may be
provided at any point during activities described by subparagraphs (A) and (B)
of this paragraph only:
(i) when projected
unobligated funds are projected to be insufficient to take clients (or
additional clients) off the waiting list and maintain continuous program health
care benefits coverage for those clients or when projected unobligated funds
may lapse if not expended in this manner;
(ii) as long as program unobligated funds are
available; and
(iii) if the
outstanding bills for health care benefits are for dates of service that are
within the time period that program unobligated funds are available and
provided the client was eligible for program health care benefits at the time
of the dates of service;
(D) if the program projects that the amount
of funds to be expended by the program in the fiscal year will be less than the
program's appropriated funds and other available resources after no clients
eligible for program health care benefits remain on the waiting list, the
program may take the following actions in the following order:
(i) eliminate limitations on prior
authorization for family support services;
(ii) provide prior authorized coverage of
diagnosis and evaluation services for applicants who qualify for up to 60 days
of program coverage for diagnosis and evaluation services only;
(iii) remove any of the additional measures
taken to reduce or limit the amount of funds to be expended by the program as
directed by rule;
(iv) remove any
reductions or limitations to contractor reimbursements that have been
implemented; and
(v) expand program
services.
(2)
In an effort to expend unobligated funds resulting from program actions taken
according to subsection (c) of this section (unobligated cost savings funds
that remain after all clients with urgent need for health care benefits have
been removed from the waiting list and provided health care benefits), the
program shall utilize the following steps in the order listed only until the
program projects that the estimated amount of unobligated funds will be
expended by the program during the fiscal year:
(A) take additional clients off the waiting
list according to the original date and time that starts the client's latest
uninterrupted sequence of eligibility for program health care benefits and in
the following group order:
(i) clients who
are less than 21 years old who do not have an urgent need for health care
benefits and who are clients who were placed on the waiting list when they were
ongoing clients and who have had no lapse in eligibility while on the waiting
list;
(ii) clients who are 21 years
of age or older who do not have an urgent need for health care benefits and who
are clients who were placed on the waiting list when they were ongoing clients
and who have had no lapse in eligibility while on the waiting list;
(B) provide health care benefits
(which may or may not include coverage of outstanding bills for health care
benefits) as stipulated in paragraph (1)(B) of this subsection for these
clients taken off the waiting list;
(C) provide limited health care benefits for
clients identified in subparagraph (A)(i) and (ii) of this paragraph who are on
the waiting list and remain on the waiting list, payment of outstanding bills
for health care benefits for clients identified in subparagraph (A)(i) and (ii)
of this paragraph who are on the waiting list and remain on the waiting list,
or payment of outstanding bills for health care benefits for clients who have
been taken off the waiting list. The program's coverage of such health care
benefits may be limited in scope, amount, and duration and is not intended to
be sustained over time. If limited health care benefits coverage includes
coverage of family support services, the coverage of family support services
must be limited according to the parameters set forth in subsection
(b)(2)(C)(i) of this section. This coverage may be provided at any point during
activities described by subparagraphs (A) and (B) of this paragraph and only as
stipulated in paragraph (1)(C)(i) - (iii) of this subsection;
(D) remove any of the additional measures
taken to generate cost savings by rule according to subsection (c)(1)(C) of
this section; and
(E) remove any
reductions or limitations to contractor reimbursements that have been
implemented.
(e) The program shall establish a protocol to be used by the medical director or other designated medical staff to determine whether a client has an "urgent need for health care benefits" by considering criteria including, but not limited to, the following:
(1) the physician or dentist who signs the
client's application or the treating physician or dentist attests or documents
the physician's or dentist's determination that delay in receiving health care
benefits could result in loss of life, permanent increase in disability, or
intense pain and suffering;
(2) the
client or family states that no other source of health insurance coverage is
available to the client;
(3)
information on the application for health care benefits indicates the
complexity of the client's condition or need for care;
(4) information received from program
regional case management staff or contractors supports other information
gathered or indicates that a delay in health care benefits could reasonably be
expected to result in an out-of-home placement or institutionalization of the
client because the family cannot continue to care for the client; and
(5) information obtained from diagnosis and
evaluation services as prior authorized by the program medical director or
other designated medical staff.
(f) The program central office may establish and administer the waiting list for health care benefits to address a budget shortfall.
(1) In order to facilitate
contacting clients on the waiting list, the program shall collect information
including, but not limited to the following:
(A) the client's name, address, and telephone
number;
(B) the name, address, and
telephone number of a contact person other than the client;
(C) the date of the client's earliest
application for health care benefits;
(D) the date on which the client became
eligible for health care benefits;
(E) the client's functional limitations or
needs;
(F) the range of services
needed by the client; and
(G) a
date on which the client is scheduled for reassessment.
(2) The waiting list is maintained
continually from one fiscal year to the next. Clients must maintain eligibility
for health care benefits to remain on the waiting list. A lapse of eligibility
for health care benefits constitutes loss of position on the waiting
list.
(3) The program shall refer
clients on the waiting list to other possible sources of services and shall
contact waiting list clients periodically to confirm their continuing need for
program services.
(4) The program
will offer case management services as needed or desired to all clients who are
eligible for health care benefits including those on the waiting list for
health care benefits.
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